What Is Patient-Centered Care? What Isn’t Patient-Centered Care?

My last post discussed the wide gulf between healthcare and the rest of the world in the area of customer service. To sum up what took over 1000 words to express: customer service in healthcare totally sucks because the system promotes that suckiness and does nothing to penalize docs who make people wait, ignore what they say, rush through visits, and over-charge for their care. We get what we pay for.

But shouldn’t we judge the system for what it was build for: the quality of the care we give? Sure, the service is overwhelmed with serious suckitude, but that can be forgiven if we give good quality care for people, right?

Even if that was the case, there is no excuse for the lousy service people get from our system. The lack of respect we, as medical “professionals” show to our patients undermines the trust our profession requires. Why should people believe we care about their health when we don’t care about them as people? Why should they respect us when we routinely disrespect them? No, the incredibly poor service we have all come to expect from hospitals and doctors is, and never should be overlooked or forgiven.

Still, I already wrote a post about that. Go back and read it if you missed it. This post isn’t going anywhere. Now I want to cover the actual care we give, and how it too has moved away from the needs of the people it is supposedly for. The people question how much providers care (verb) mainly based on the (lousy) service they get. The care (noun) we give is all about the quality of the product purchased by whoever pays for that (be they third-party or the patients themselves). The real question I am asking here is not if this care is good or bad (the answer to that is, yes, it is good and bad), but whether it is patient-centered.

This should be a silly question, like asking if car-repair is car-centered. But it is clear that much of the high cost of care in our country is due to the huge number of unnecessary procedures, medications, hospitalizations, and services given to/done on people. Unnecessary care is, almost always, not patient-centered.

There are many reasons for unnecessary care, including:

Defensive care, where the provider knowingly does unnecessary things to protect themselves from perceived legal threat. For example, a baby in the ER with a fever will often get a chest x-ray and lab tests drawn. In my office, babies with fevers get a good history and physical. Labs and x-rays are only done when I am still not certain after the H&P.

Protocol-driven care, where care is ordered because the provider is under the impression that they are being measured for a certain item of care. While this is sometimes appropriate, it is often either a bad guideline (such as checking cholesterol in low-risk populations, or doing PSA testing in men over 65), or a misinterpretation of the guidelines (such as doing mammography or colonoscopy in the elderly).

Profit-driven care, where the provider simply orders something because they can rationalize it and it is paid for. Once, in my previous practice, we got part ownership in some x-ray equipment. Very soon after getting this, we noticed that far more people with coughs were getting chest x-rays and far more people with knee pain were getting (you guessed it) knee films. Our care didn’t improve, it simply got more expensive (and profitable). Other examples of this are the annual lab profiles many physicians order when their office owns lab equipment (despite a lack of evidence that they improve care).

Add to this the high percentage of office visits that are not necessary but are done because they are the physicians’ only means of payment for care (about 75% when I last counted), and you get a glimpse of just how much care done in the US is not necessary.

This is the antithesis of patient-centered care.

It is costly.

It exposes the patient to risk from the procedures.

It exposes them to the risk of over-diagnosis.

It does nothing to actually help the patient.

So again I turn to my experience over the past 3 years in a practice where I am financially obligated to give the best care possible. What does good care look like? More specifically, is good care the same thing as patient-centered care?

I think the answer to the second is “mostly yes.” Most of the time the care I give looks toward what is best for people and not at other things. I say “mostly” because there are some circumstances in which the patient as a customer works against good care, and I feel significant pressure to keep the customer happy by giving lower-quality care. The main time this happens is when people demand antibiotics for conditions in which antibiotics don’t help. Sinusitis, bronchitis, and most pharyngitis gets better without any medication, and giving antibiotics just raises risk of adverse reactions or drug-resistant bacteria. But people still believe antibiotics are wonder-drugs and are often impatient to get well. So where do I give in to them for the sake of keeping their business? It does happen. It always will happen to some degree. But I will state categorically that it happens much less in my current practice than it did in my old one, as I have much more time to educate people, and they don’t feel nearly the pressure to walk out of my office with “something to show for it” (since access to me is easy).

So what is true patient-centered care? I think there are two main things that define patient-centeredness in care:

1. It is focused on decreasing the risk of problems.

The first question I ask when someone comes to my office with a complaint or problem is: “what are the most important things to rule-out?”. Someone with chest pain, for example, needs to be ruled-out for heart problems. This is usually done by listening to the story, but sometimes requires further testing.

The same criteria can be used for any testing or treatment. Does giving the medication decrease the person’s risk, or does it increase it. Giving a statin drug to a 60 year-old diabetic who smokes is probably something that will lower their risk of death from heart attack or stroke. Giving that same drug to a 30 year-old who has no other risk factors (but has the exact same cholesterol profile) is likely to increase their risk of problems. All care needs to be ordered and explained from this perspective. I recommend flu shots to high-risk people, explaining that it makes it more likely they will be around in a year (to which one of my patients responded: “what if I only want 6 months?” Smart ass).

2. It is focused on improving quality of life.

Once bad stuff is ruled-out, the focus turns to the other reason people seek care: they want to feel better. Many times I’ve heard of people with knee pain who get an x-ray and are simply told it is “normal,” without any treatment for the pain itself (perhaps the doc thinks the x-ray is therapeutic?). I’ve heard other exasperated people tell of times they’ve been told that, despite significant distress, “nothing’s wrong.” While I think often the doc is simply being clueless or socially inept, it raises an implied accusation that the person is making things up or wildly exaggerating. This is often taken as what it is: an insult.

Again, all testing and treatment needs to be oriented toward this question as well. Does the testing increase the ability to improve a person’s quality of life? If it identifies risk or avenues of treatment, then it shouldn’t be done. If a medication doesn’t make a person feel better or, conversely, if it has significant side-effects, it shouldn’t be given (unless it substantially reduces risk).

One of the main problems with the care given by many providers is that, even if these issues are considered they aren’t discussed with the patient. This is a way in which my current situation greatly favors patient-centered care in that I have time to explain why we might want to use a medication with potential side-effects (or even risks) if it improves risk or quality of life enough. People are far more open to taking medications that they understand, but it is our job to explain this.

There are two other issues related to this that I’m going to cover in upcoming posts:

Any treatment or testing is useless if the patient cannot afford it. Patient-centered care will always be very conscious and conscientious of the cost.

What does patient-centered care look like when the patient doesn’t follow the course recommended by the doctor? In other words, how does patient-centeredness work with non-compliant patients?

Perhaps the word “metrics” is a problem here. I think true patient-centered care would see metrics as secondary, not primary. I know that’s difficult to implement and test, but the changing of care from what it is to true patient-centered are is one in which the system no longer overwhelms the providers with metrics and lets it somehow go back to communication and education.

I’ll use gizmos and gadgets and data to make my practice better and to communicate better with my patients, but I resolve to never let that technology come between me and my patient. And when it does I will turn it off.

Have you seen Don Berwick on patient-centered care? Check this out in Health Affairs 2009: http://content.healthaffairs.org/content/28/4/w555 Too bad he didn’t execute his proposal when he headed CMS. The title of his article is: What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist; A seasoned clinician and expert fears the loss of his humanity if he should become a patient. by Donald M. Berwick I love it.

Wish I could see full-text and not just the abstract. Sounds like a prescient paper.

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William Palmer MD

Apr 13, 2016

A good discussion, Robert.

It is fun to think about what a doctor’s principle role should really be. It would be great if we could prevent everything and go home. Pretty fanciful, circa 2000 c.e.

Or, are we merely to correct health problems with a return to some average population baseline or insurance coverage constraint? Or, are we ideally to try to maximize all the physiology–body and brain– and go above and beyond banal health and bring people into some sort of super health and nirvana? This latter might be our goal in fifty years, but is surely unaffordable now.

A real problem is that, at least genetically, we all have something wrong. Francis Collins said this. Eg look at one of the necessary metabolites, pyridoxine, B6. Some folks need 1 mg per day of this stuff and some need a hundred times more. A huge number of folks have beta thal. Ditto, sickle cell trait. 1% have schizophrenia. 8-10% have hypertension. 6% or more have diabetes. A few percent have celiac disease and hemochromatosis and cystic fibrosis. On and on we go. There are some four thousand recognized diseases of matabolism.

Therefore, when you look at the Byzantine complexity of our biochemistry, it seems as if we are all probably vastly underdiagnosing. And in mental health, it feels as if the entire population of the US has someting. :-(.

A simple, less epic, way to look at our role is less glamorous and could be said to be: Docs are here to make people feel better. Period. So maybe a realistic goal should be not to be exhaustive and perfect but simply say that each patient should feel a little better after each of our care episodes…the derivative should slope upward.

I really think the idea of “entering the patient’s narrative” is what I focus on. The patient has a life narrative and our task, when they come to us, is to enter that narrative, return it to its preferred course, and assure that there is nothing impending that will mess up their narrative. By this I mean that we are not who the story is about (although we have our own narratives), and our attempts to make the doctor-patient relationship about us has created all sorts of trouble.

Your comment has convinced me of what the next topic I cover should be. I am very much like you in that the contemplation of the bottom line: why are we doing what we do, is always something I’m asking. Thinking simply at the foundation (i.e. Making each patient feel a little better and moving the derivative slope upward) doesn’t mean there are not layers of complexity above, but it guides how we practice. Great thoughts.

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